Background

Our hands are often involved in minor scrapes, burns, cuts and bruises. Occasionally, larger wounds result that require surgical intervention to preserve hand function.

Causes

In the hand and upper extremity, soft tissue defects can result from various causes, including trauma, infection and cancer, among many others. On occasion, a surgical incision doesn’t heal well, or if there is infection or hematoma, an open wound will result that will require intervention. Dr. Dowlatshahi has extensive experience with soft tissue reconstruction of the hand and will often get referrals from other hand surgical colleagues to assist when the need arises.

Symptoms

Open wounds can be painful, especially if in sensitive areas such as the fingertips or palm. They can drain quite a bit and require frequent bandage changes. If infection sets in, the drainage can increase and become purulent, and there can be an increase in swelling and redness, called cellulitis. If the infection enters the lymphatic system, a red streak can appear along the forearm which is called “lymphangitis”.

Diagnosis

Physical examination is paramount. Other important measures are taking a culture to identify any bacterial organisms. Xrays can assess whether there is any bony involvement, such as underlying fracture from trauma, or infection involving bone. A biopsy is important to consider if a form of cancer is suspected. Advanced imaging such as CT scan or MRI can help address any further bone or soft tissue involvement and help with operative planning.

Treatment

Soft tissue reconstruction can range from skin grafts to more complex reconstructive procedures involving various types of flaps.

In all of these cases, it is of utmost importance to address bony/skeletal, as well as blood vessel, nerve and tendon/muscle reconstruction. Merely closing the defect is often not enough since form and function are critically linked in the upper extremity. This is where the orthoplastic approach comes in.

In this section Dr. Dowlatshahi demonstrates relatively straightforward cases where soft tissue reconstruction was obtained by simple graft or flap coverage. For more complex applications of orthoplastic principles please see the Orthoplastic and Reconstructive Microsurgery section.

Skin grafts

Split or full thickness skin grafts are part of the basic armamentarium of the hand surgeon to reconstruct a gamut of skin defects from the elbow to fingertip.

Whether a graft is used as a split thickness graft (which contains only the upper, more superficial layers of skin) or a full thickness skin graft, depends on the individual circumstances. Often, more than one option is possible. Dr. Dowlatshahi will be glad to provide guidance after he has had a chance to review your case.

Here, several examples are presented.

In this case, the patient had undergone removal of a sarcoma of the forearm. The resulting wound was rather superficial.

Dr. Dowlatshahi discussed the options with the patient and performed a split thickness skin graft.

2 months postop, the graft is well healed. Refinement of the result with a soft tissue revision was discussed, but the patient was satisfied with the result and elected to leave the area alone.

This is another example of a split thickness skin graft that was used to reconstruct a skin cancer defect on the dorsal aspect of the hand. In this area, grafts as opposed to flaps provide a more satisfactory result since they are thinner and provide a more aesthetic and functional result, matching more closely the appearance of normal skin.

In this case, Dr. Dowlatshahi used artificial skin first, followed by a split thickness skin graft in a separate step. The artificial skin build the wound up and allows for a better glide layer, once the graft is healed. The origin of the skin loss was a severe soft tissue infection (necrotizing fasciitis).

Flaps

Numerous soft tissue flaps are available for coverage of soft tissue defects of the hand and upper extremity. In this section we present some of the more common options. In the Orthoplastic and Reconstructive Microsurgery section, more sophisticated options are presented.

For fingertip injuries, we commonly utilize flaps that we take from the same digit.

The volar VY advancement is a common reconstruction of the finger pulp and can be even done under a local anesthetic in the office or emergency department. This technique was originally described by Atasoy and involves advancing a triangle of tissue over the fingertip to provide coverage to the exposed bone.

The homoditial reverse flow island flap is a powerful method to reconstruct fingertip defects when the volar VY flap of Atasoy isn’t possible. The original technique sacrifices the nerve on the affected side of the finger, but Dr. Dowlatshahi performs a nerve sparing approach when possible.

The homodigital island flap can actually be used for coverage of the PIP and MCP joints. This technique is often forgotten but can be a very useful tool in difficult cases when other options aren’t available.

This following case demonstrates the use of this flap for coverage of an MCP joint in a patient that lacks all other options.

The donor site was grafted using a full thickness skin graft.